<!DOCTYPE html>
<html>
  <head>
    <meta charset="UTF-8">
    <title></title>
  </head>
  <body>
    <form action="http://www.google.com/" method="post">
        <fieldset>
            <h3 class="box-subtitle facturacion-subtitle">DATOS DEL TITULAR DEL MEDIO DE PAGO</h3>
            <div class="form-content noResumenSessionBillings ">
                <div class="row">
                    <div class="col-xs-12 col-sm-6 col-md-6 col-lg-6 form-group">
                        <label>Nombre <span class="required" aria-required="true">*</span></label>
                        <input type="text" name="firstName" id="firstName" autocomplete="given-name" class="form-control" value="" title="Nombre" placeholder="Como figura en tu documento" aria-required="true" tabindex="3" required="" autofocus="">
                    </div>
                    <div class="col-xs-12 col-sm-6 col-md-6 col-lg-6 form-group">
                        <label>Apellido <span class="required" aria-required="true">*</span></label>
                        <input type="text" name="lastName" id="lastName" autocomplete="family-name" class="form-control" value="" title="Apellido" placeholder="Como figura en tu documento" aria-required="true" tabindex="4" required="">
                    </div>
                </div>
                <div class="row">
                    <div class="col-xs-12 col-sm-6 col-md-6 col-lg-6 ">
                        <div class="row ">
                            <div class="col-xs-4 col-sm-4 col-md-4 col-lg-4 dni form-group">
                                <label>Tipo <span class="required" aria-required="true">*</span></label>
                                <div class="form-group">
                                    <select class="gb-select" id="id_type" name="id_type" tabindex="7">
                                        <option value="DNI" selected="selected">DNI</option>
                                        <option value="CI">CI</option>
                                        <option value="LC">LC</option>
                                        <option value="LE">LE</option>
                                    </select>
                                </div>
                            </div>
                            <div class="col-xs-8 col-sm-8 col-md-8 col-lg-8 dni-numero form-group">
                                <label>Número de documento <span class="required" aria-required="true">*</span></label>
                                <input type="tel" name="id_value" id="id_value" class="form-control" value="" title="Nro de Documento" aria-required="true" tabindex="8" autocomplete="new-doc" required="">
                            </div>
                        </div>
                    </div>
                    <div class="col-xs-12 col-sm-6 col-md-6 col-lg-6 ">
                        <label> Fecha de Nacimiento <span class="required" aria-required="true">*</span></label>
                        <div class="row fecha-nacimiento ">
                            <div class="col-xs-3 col-sm-3 col-md-3 col-lg-3 inline form-group fecha-dia">
                                <select id="day_select" class="gb-select" name="day_select" aria-required="true" tabindex="9" required="">
                                    <option value="0">Dia</option>
                                    <option value="01">1</option>
                                    <option value="02">2</option>
                                    <option value="03">3</option>
                                    <option value="04">4</option>
                                    <option value="05">5</option>
                                    <option value="06">6</option>
                                    <option value="07">7</option>
                                    <option value="08">8</option>
                                    <option value="09">9</option>
                                    <option value="10">10</option>
                                    <option value="11">11</option>
                                    <option value="12">12</option>
                                    <option value="13">13</option>
                                    <option value="14">14</option>
                                    <option value="15">15</option>
                                    <option value="16">16</option>
                                    <option value="17">17</option>
                                    <option value="18">18</option>
                                    <option value="19">19</option>
                                    <option value="20">20</option>
                                    <option value="21">21</option>
                                    <option value="22">22</option>
                                    <option value="23">23</option>
                                    <option value="24">24</option>
                                    <option value="25">25</option>
                                    <option value="26">26</option>
                                    <option value="27">27</option>
                                    <option value="28">28</option>
                                    <option value="29">29</option>
                                    <option value="30">30</option>
                                    <option value="31">31</option>
                                </select>
                            </div>
                            <div class="col-xs-6 col-sm-6 col-md-5 col-lg-6 inline form-group fecha-mes">
                                <select name="month_select" id="month_select" class="gb-select" aria-required="true" tabindex="10" required="">
                                    <option value="0">Mes</option>
                                    <option value="01">Enero</option>
                                    <option value="02">Febrero</option>
                                    <option value="03">Marzo</option>
                                    <option value="04">Abril</option>
                                    <option value="05">Mayo</option>
                                    <option value="06">Junio</option>
                                    <option value="07">Julio</option>
                                    <option value="08">Agosto</option>
                                    <option value="09">Septiembre</option>
                                    <option value="10">Octubre</option>
                                    <option value="11">Noviembre</option>
                                    <option value="12">Diciembre</option>
                                </select>
                            </div>
                            <div class="col-xs-3 col-sm-3 col-md-4 col-lg-3 inline form-group fecha-anio">
                                <select name="year_select" id="year_select" class="gb-select" tabindex="11" data-validate="">
                                    <option value="0">Año</option>
                                                <option value="2001">2001</option>
                                                <option value="2000">2000</option>
                                                <option value="1999">1999</option>
                                                <option value="1998">1998</option>
                                                <option value="1997">1997</option>
                                                <option value="1996">1996</option>
                                                <option value="1995">1995</option>
                                                <option value="1994">1994</option>
                                                <option value="1993">1993</option>
                                                <option value="1992">1992</option>
                                                <option value="1991">1991</option>
                                                <option value="1990">1990</option>
                                                <option value="1989">1989</option>
                                                <option value="1988">1988</option>
                                                <option value="1987">1987</option>
                                                <option value="1986">1986</option>
                                                <option value="1985">1985</option>
                                                <option value="1984">1984</option>
                                                <option value="1983">1983</option>
                                </select>
                            </div>
                        </div>
                    </div>
                </div>
                <div class="row">
                    <div class="col-xs-12 col-sm-12 col-md-12 col-lg-12 form-group genero">
                        <label class="title-genero">Género <span class="required" aria-required="true">*</span></label>
                        <div class="row">
                            <div class="col-xs-12 col-sm-12 col-md-12 col-lg-12">
                                <div class="item-genero">
                                    <input type="radio" aria-required="true" id="masculino" name="gender" autocomplete="sex" value="MALE" tabindex="13" required="">
                                    <label for="masculino">Masculino</label>
                                </div>
                                <div class="item-genero">
                                    <input type="radio" aria-required="true" id="femenino" name="gender" autocomplete="sex" value="FEMALE" tabindex="12" required="">
                                    <label for="femenino">Femenino</label>
                                </div>
                            </div>
                        </div>
                    </div>
                </div>
            </div>

            <h3 class="box-subtitle facturacion-subtitle">DATOS DE CONTACTO</h3>

            <div class="form-content resumenSessionContact ">
                <div class="row">
                    <div class="col-xs-12 col-sm-6 col-md-6 col-lg-6 form-group">
                        <label>E-mail <span class="required" aria-required="true">*</span></label>
                            <input type="email" name="email" id="email" autocomplete="email" class="form-control" value="" title="Email" placeholder="Ingresá tu e-mail" aria-required="true" tabindex="13" required="">
                    </div>
                    <div class="col-xs-12 col-sm-6 col-md-6 col-lg-6 form-group">
                        <label>Teléfono <span class="required" aria-required="true">*</span></label>
                        <input type="tel" name="phone" id="phone" autocomplete="tel" class="form-control" value="" placeholder="Ej: 1145887000" tabindex="14" aria-required="true" required="">
                    </div>
                </div>
            </div>
        </fieldset>
    </form>
  </body>
</html>
